CASE HISTORY .com



CASE HISTORY(keep this font/size and spacing) (you can delete anything in parentheses)Identifying InformationName:Age: Gender:Race/Ethnicity:Relationship Status:Therapist:Date: Primary Presenting ConcernDevelopment and Life HistoryMedical and Mental Health HistoryInterpersonal RelationshipsCurrent PresentationStrengths and AssetsContributing Sociocultural FactorsCBT ASSESSMENTPresenting Problems (number and describe each separately; consider precipitating and maintaining factors)1.2.(Etc.)Motivation and Responsibility to ChangeFormal Symptom Measures(See “Panic Disorder and Severity Scale – Self-Report Form” and “Agoraphobia Scale”)(1. Report/Explain assessment results.)(2. How is this information helpful to understand case?)(3. How information can be used in therapy?)CBT CASE FORMULATIONCross-Sectional ViewLongitudinal ViewNomothetic Formulation (remember – this is the “academic” general theoretical understanding)Working Hypothesis (remember – this is your “clinical” CBT conceptualization of the client; full integration of history and present distress; matching nomothetic)DSM-5 Diagnosis (provide rational for each diagnosis based on case information and DSM criteria)CBT TREATMENT PLANTreatment Goals and Interventions (number each goal – concrete and measureable; list and describe interventions per goal, including specific to client; logical treatment order) Goal 1:Intervention 1:Intervention 2:Goal 2:(Etc.)Anticipated Obstacles (i.e., therapeutic relationship considerations, client specific factors, external factors)Additional information that could have been helpful?(This serves two purposes: [1] It shows some clinical judgment on your part with regard to determining what information you would follow-up on after intake. [2)] It can be helpful for me to improve future revisions of this case study [knowing that even the most thorough of case studies will never provide all information – there will always be some “gaps”].) ................
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